4/16/2016 Disclosures Consultant, Volcano Corporation Behaviorism and Compliance: Objectives Often Overlooked, Critically Important UCSF Vascular Symposium 2016 Define the compliance and non-adherence Understand the role of behavioral health and non-adherence Jonathan Labovitz, DPM Medical Director, Foot & Ankle Center Appreciate the role and importance of behavioral health and Associate Professor, College of Podiatric Medicine non-adherence in the diabetic foot Western University of Health Sciences Providing Value Providing Value Why does behavior matter? Why does behavior matter? THE IMPACT OF BEHAVIORAL HEALTH THE IMPACT OF BEHAVIORAL HEALTH Population health requires a “holistic” approach Behavior impacts compliance Treat the patient not the limb � What is it like to live with a hole in your foot? …without a leg? Understand social determinants of health Compliance impacts… � How do the changes affect your family and friends? � Population health � Costs and utilization Based on the personal impact of the clinical outcomes, was the care received valuable ? 1
4/16/2016 Behavioral Health PROVIDING VALUE Compliance vs. Adherence • The extent a patient’s behavior coincides with Compliance FUNCTIONAL LIMB SALVAGE medical advice • Cooperation or obedience We assess functional results as physical ability, mobility, and/or return of independence • Relies on remaining constant Adherence • The persistence in practice, steady observance or What about motivation, desire and willingness? maintenance • Reflects patient’s tenacity to maintain behavioral change over time • Implies patient’s active choice Patient’s Psychological Perspective Compliance vs. Adherence • Limitations in capacity and the patient’s Un intentional resources (e.g., forgetfulness, dexterity, Non-Adherence Habitual Behaviors Personality knowledge) Mood Traits Behavior • Inadequate understanding of disease/condition being treated • Modify or completely reject the advice Intentional • No attempt to undermine or discredit the Dr Patient’s Patient’s Non-Adherence Reaction to Reaction to Daily disease Daily disease Develop Develop assessment of assessment of • Conscious choice Diagnosis Diagnosis management management complications complications disease & risks disease & risks • Based on the… • Beliefs about disease severity, complications risk, potential benefits of treatment • Culture , circumstances, priorities, preferences, experiences 2
4/16/2016 Reacting to the Doctor RESPONDING TO COMPLICATIONS Emotional responses Behavioral responses Scared 50% Improve self-care 45% The patient reaction to a Sad 38% Not knowing what to do 15% provider discussion about a new onset Angry 31% Do nothing 13% complication Guilty 27% Want to give up 11% Hopeless 17% � 75% of patients > 1 “Wake-up” call 46% microvascular complication Value of supporting the patients Diabetes Mellitus and “Wake-up” call 54% � 57% eye Feels supported 40% nerve Improved self-care 58% IMPACT OF DEPRESSION 29% renal “Wake-up” call 36% Doesn’t feel supported Improved self-care 27% Non-alarmist Answered ? Support = the Dr. Specific recommendations Non-punitive Weinger K. Abstract presented at the American Diabetes Association 75 th Scientific Sessions, 2015 Depression and Diabetes Mellitus Depression and Foot Complication Risk DEPRESSION AND TREATMENT ADHERENCE Diabetic Foot Ulcers Major depression = 2-fold increased risk of incident ulcers Depression = Treatment adherence Williams LH, et al. Am J Med, 2010 � 2-fold increased risk of non-healing foot ulcer PSYCHOSOCIAL MPACT OF DEPRESSION CLINICAL IMPACT OF DEPRESSION � 5-fold increased risk of ulcer recurrence Social issues � Decreased HRQoL Monami M, et al. J Am Pod Med Assoc, 2008 � Unhealthy diet � Decreased foot self-care � Obesity, Exercise � Increased number and Lower Extremity Amputations � Sedentary lifestyle severity of diabetes related � 33% higher risk of incident major amputation � Tobacco use complications � Societal burden � 12% higher risk of any amputation Increased risk Increased risk Increased risk Increased risk Depression Depression � No significant increased risk of minor amputations DPN & PAD DPN & PAD DFU & Amputation DFU & Amputation Depression can precede and/or follow onset diabetes complications Williams LHC, et al. J Diabetes Complications, 2011 Nguyen AL et al. J Diabetes Complications 2015; Simon GE, et al. Gen Hosp Psychiatry 2005; Egede LE, et al. Gen Hosp Psychiatry 2009; Kivimaki M, et al. Diabetes Med 2007 3
4/16/2016 Cognition Non-Adherence IMPACT: PATIENT EDUCATION AND INSTRUCTIONS • Is the patient able to process, understand, or remember them? • Is the patient able to focus, organize thoughts to implement them? The patient may lack the cognitive ability to adhere to treatment plans Cognitive Ability and Diabetes Mellitus It may not be the patient’s fault… It could be our ours! Cognition = Treatment adherence NON-ADHERENCE The diabetic foot is a complex systemic condition including cognitive deterioration N atovich R. Abstract at ADA 75 th Scientific Sessions, 2015 Cognition and Diabetes Mellitus Cognition and Diabetes Mellitus COGNITIVE ABILITY & DM FOOT DISEASE DIABETES & COGNITIVE DYSFUNCTION IMPACT OF COGNITIVE DYSFUNCTION Cognitive Impairment Impaired global cognition Global cognition impaired Low mental health function 75% � 50% age > 65 63% 50% 60% 54% Cognitive domains impacted Lower extremity amputation Increase DFU odds > 4x 53% 52% � 25% 32% � Global cognition impaired (OR = 3.59) Memory � Independent risk factor for � 0% � Episodic memory deficit (OR = 4.13) Major LEA Reaction time � Mobility Microvascular disease & episodic Attention � � memory deficit (OR = 9.68) Independence S/P LEA Executive functioning � � Falls Psychomotor skill � � CONCLUSIONS � Cognitive impairment after lower limb amputation is common and under-diagnosed Natovich R. Abstract at ADA 75 th Scientific Sessions, 2015 Tseng C, et al. Gen Hosp Psychiatry, 2007 � Increased odds of cognitive deficits in microvascular disease Marseglia A, Xu W, Rizzuto D, et al. J Diabetes Complications, 2014 4
4/16/2016 Alcohol Dependence and Diabetes Mellitus ALCOHOL CONSUMPTION Alcohol consumption a coping mechanism but makes neuropathy worse and possible synergistic effects with hyperglycemia Altenburg N, Joraschky P, Barthel A, et al. Diab Med 2011 ALCOHOL AND ADHERENCE TO SELF-CARE 772 T2DM patients at high-risk for foot complications at 8 VAMC Behaviorism and Compliance • Adherence to foot self-care recommendations = 32.2% • Depression history = 33.2% but no significant effect on adherence to CRITICALLY IMPORTANT foot self-care • No alcohol/drug dependence added to predictability of patient performing self-care Johnston MV, Pogach L, Rajan M, et al. JRRD 2006; 43(2): 227-238 Diabetes and Decreased HRQoL PROVIDING VALUE: DIABETES MELLITUS CRITICALLY IMPORTANT No T2DM > DM > many other chronic illnesses Complications the most important variable Higher Lower Diabetic Foot Ulcers HRQoL HRQoL � Minor LEA > DFU � DFU = Major LEA QoL all physical & psychosocial domains Ribu L, et al. J Diabetes Complications, 2008; Siersma V, et al. J Foot Ankle Surg, 2014 5
4/16/2016 Critically Important: Readmissions T2DM, Low HRQoL, & Non-Adherence Source: HCUP Statistical Briefs #153 & #154, 2010 READMISSIONS IN PATIENTS W/ DIABETES, 2010 READMISSIONS IN DM PATIENTS BY ADMITTING DX FOOT CARE NON-ADHERENCE & HRQoL 31.6 35 Percentage readmitted ✔ ✔ ✔ 30 500 patients 21.3 97.8 25 20.3 100 w/out complications 17.2 Overall HRQoL 20 15 11.2 8.5 • T2DM > 1 yr 10 with complications 80 5 0 • Age > 25 y.o. 60 • Outpatient 40 20.3 20 Adherence Rate Diagnosis of Gangrene 8.5 1.8 Exception? 0 2 nd highest readmission rate Readmit/1,000 % readmit Usual Pain/Discom Anxiety/Dep 60% 75% of Mobility Self-care activities fort ression READMISSIONS IN PATIENTS W/ DIABETES MELLITUS BY PROCEDURE patients 44.8% 40% 43.2% 37.0% 37.2% 33.2% Highest readmission rate % Readmitted w/anxiety 20% (30 most common showed self Debridement wound, infection, or burn 19.1 procedures) 0% LE vascular bypass 20.7 foot-care Blood Foot care Diet Exercise Smoking Lower extremity glucose Amputation of lower extremity 22.8 adherence amputation monitoring 17 18 19 20 21 22 23 24 Saleh F, Mumu SJ, Ara F, et al. BMC Public Health 2014; 14: 431-438 Behavioral Health, Cost & Utilization Unpublished data Critically Important: Depression Cost & Utilization The Impact of Behavioral Health Conditions on Length of Stay and Acute Care Costs in Inpatient foot complications Depression prevalence in T2DM with Lower Extremity Complications diabetic inpatient care in ± depression CA, 2010 - 2013 LOS Cost (x1,000) 25 Length of Stay / Cost in USD) ^ * * $22.35 * $22.05 * ^ * 5.6% increased cost $20.92 $20.71 20 $19.70 $19.66 $19.62 $18.48 No foot $16.58 6.4% 15 complication 10 * * * * 8.6 LOS * 8.1 * 7.5 7.5 Foot 7.0 6.8 6.9 6.1 11.1% 5 5.5 complication 31.2% longer 0 0.0% 10.0% 20.0% More services, Higher Costs, Less effective care Behavioral Health Condition * p < 0.0001 ^ p < 0.05 Unpublished data - CA OSHPD Public Discharge Files 2010-2013 6
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